SEPSIS, SHOCK

& MODS

Jozef Firment, MD, PhD.

Department of Anaesthesiology &

Intensive medicine, Medical faculty

UPJŠ Košice

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DEFINITION OF SHOCK

• Complex syndromme developed by

insufficient capillary nutritional

perfusion of tissues.

• Censequences: deficiency of oxygen &

energetical resources in tissues

= pathological metabolism &

cummulation of toxic products.

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PATOPHYSIOLOGICAL

TYPES OF SHOCK

• Hypovolemic

– (dehydration, haemorrhage)

• Distributive

– (spine laesion, high-level spinal anaesthesia, anaphylactic, septic)

• Obstructive

– (pulmonary embolism, hydropericard)

• Cardiogenic

– (AMI)

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HYPOTENSION

Interpretation:

belove 0,5 = normal find out

above 1,0 = necessary of treatment

Cave! Digitalis, beta-blockers, cardiostimulators...

Shock index =

Sh

ock s

ign

s

pulse rate

systolic BP

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LABORATORY SIGNS

MLAC > 2 mmol/l

OLIGURIA

Diuresis < 0,5 ml/kg/hour

Sh

ock s

ign

s

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PREHOSPITAL PHASE –

FIRST SIGNS

(circulatory parameters):

• BP, P, circulatory centralisation, slow

capillary return, SpO2, cold sweat

• restlessness-lethargy, shivering...

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SHOCK ACCORDING TO

CLINICAL REASONS

• anaphylactic shock (alergy to medicaments, to

venom...)

• neurogenic shock spinal shock (spinal cord

laesion, high spinal anaesthesia...)

• haemorrhagic shock

• traumatic shock

• burn shock

• toxic shock (pancreatitis...)

• septic shock (sepsis...)

• cardiogenic shock (AMI...)

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CIRCULATORY

PARAMETERS

BP P SVR

Hypovolemic

Cardiogenic / /()

Septic hyperdyn.

Septic hypodyn.

Neurogenic

Anaphylactic /

= may not be,

/ = changes to both sides,

= increase, = dectrease, = marked increase

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INITIAL GENERAL

ANTI-SHOCK STEPS

Oxygen

Stoppage bleeding

Airway management (artif ventil?)

Analgesia, tranquilisation

Anti-shock position

Neutral temperature condition

Careful transport

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HYPOVOLEMIC SHOCK

• Stoppage bleeding

Autotransfusion position

Rapid iv administration fluids - colloids

(HOHO, or isovolemic solution)

Oxygen, artif. ventilation.

Improving perfusional pressure with

dopamine in R1/1 (RL1/1)

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PROGRESSION OF BLOOD LOSS

REPLACEMENT

0

10

20

30

40

50

60

70

80

90

100

Blo

od

lo

ss i

n %

CryCol Ery Alb, FFP Pt

HT

K <

25

%

Pro

tein

s <

50

g/l

Qu

ick <

35

%

Pt <

50

th

us/m

m3

3,5 3 1,5 1 Blood volume in liters

5

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ANAPHYLACTIC SHOCK Prerušiť prívod alergénu (infúzia, blokovať

jeho ďalšie vstrebávania - obstrek vpichu hmyzom trimecain c. adren, chladenie miesta alergénu...)

Inhalácia kyslíka, resp. UPV.

Autotransfúzna poloha

Rýchly i.v. prívod tekutín - koloidy (HOHO, resp. izovolemický roztok)

Glukokortikoid (Hydrocortison) 300 mg i.v.

Adrenalin titračne 1,0 mg i.v. v infúzii

Zlepšenie perfúzneho tlaku pomocou dopamínu v R1/1

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TOXIC SHOCK

• Antidótum (ak existuje)

Rýchly i.v. prívod tekutín - koloidy

(HOHO, resp. izovolemický roztok)

Inhalácia kyslíka, resp. UPV.

Zlepšenie perfúzneho tlaku pomocou

dopamínu a/alebo adrenalin

(noradrenalin) v R1/1

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SEPTIC SHOCK • Rýchly i.v. prívod tekutín - koloidy (HOHO,

resp. izovolemický roztok)

Noradrenalin a/alebo dopamín (adrenalin)

Inhalácia kyslíka, resp. UPV.

Udržiavať paO2 čo najvyššie (OTI?)

Antibiotiká

Miniheparinizácia

Chirurgické liečenie ložiska

Imunoglobulíny i.v.

Monoklonálne protilátky proti cytokínom

Hemofiltrácia

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CLINICAL SYNDROMES

• SIRS = fever + leukocytosis

• Sepsis = SIRS + infection

• Severe sepsis = sepsis + MODS (MSOF)

• Septic shock = severe sepsis +

refractery hypotension

Kerr G. E.: Some current concepts and strategies in critical care. PGA55

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Recommendations for terminology according to

ACCP/SCCM Consensus Conference (Chest, 101, 1992)

Odporúčaná terminológia:

Infekcia

Bakteriémia, virémia, fungémia, parazitémia

SIRS

Sepsa

Ťažká sepsa

Septický šok

MODS

Nepoužívať termíny: Septikémia Septický syndrom Refraktéerny šok

• Systemic Inflammatory Response Syndrome

• systémová zápalová odpoveď na (obvykle)

ťažký inzult rôznej etiológie

• diagnostické kritériá (pre dg. SIRS musia byť

prítomné minimálne dve kritériá)

TT > 38 C alebo < 36 C

srdcová frekv. > 90/min

dychová frekv. > 20/min

4000 > Leu > 12000

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Recommendations for terminology according to

ACCP/SCCM Consensus Conference (Chest, 101, 1992)

Odporúčaná terminológia:

Infekcia

Bakteriémia, virémia, fungémia, parazitémia

SIRS

Sepsa

Ťažká sepsa

Septický šok

MODS

Nepoužívať termíny: Septikémia Septický syndrom Refraktéerny šok

• Systemic Inflammatory Response Syndrome

• systémová zápalová odpoveď na (obvykle)

ťažký inzult rôznej etiológie

• diagnostické kritériá (pre dg. SIRS musia byť

prítomné minimálne dve kritériá)

TT > 38 C alebo < 36 C

srdcová frekv. > 90/min

dychová frekv. > 20/min

4000 > Leu > 12000

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CLINICAL COURSE OF

SEPSIS

• SIGNS BP Oxygenation Oxygenation BP

Fluids O2 mask Artif ventil Vasopressors

Focus elimination, antibiotics

• TREATMENT

INFECTION SEPSIS SEVERE SEPSIS SEPT. SHOCK DEATH

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INITIAL RESUSCITATION

OF SEPTIC SHOCK The resuscitation of a patient in severe sepsis or sepsis-induced tissue

hypoperfusion (hypotension or lactate acidosis) should begin as soon as the

syndrome is recognized and should not be delayed pending ICU admission. An

elevated serum lactate level identifies tissue hypoperfusion in patients at risk

who are not hypotensive. During the first 6 hours of resuscitation, the goals of

initial resuscitation of sepsis-induced hypoperfusion should include all of the

following as one part of a treatment protocol:

– Central venous pressure (CVP): 8-12 mm Hg (12-15 mm

Hg in mechanically ventilated patients)

– Mean arterial pressure (MAP) > 65 mm Hg

– Urine output > 0.5 ml/kg/hour

– Central venous (superior vena cava) [ScvO2] or mixed

venous O2 [SvO2] saturation 70%

Recommendation: Grade B

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INITIAL

RESUSCITATION

OF SEPTIC

SHOCK

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INIT

IAL

RE

SU

SC

ITA

TIO

N

OF

SE

PT

IC S

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Sepsis Bundle 6-Hour Severe Sepsis Bundle: Tasks that must be done within 6 hours for

patients with severe sepsis, severe sepsis with lactate >4 mmol/l, septic shock.

Changes for Improvement

1. Serum lactate measured

2. Blood cultures obtained prior to antibiotic administration

3. Broad-spectrum antibiotics administered within 3 hours of presentation

4. In the event of hypotension (SBP <90, MAP <70) or lactate >4 mmol/l, begin initial fluid resuscitation with 20-40 ml of crystalloid (or colloid equivalent) per estimated kg of body weight

5. Vasopressors employed for hypotension during and after initial fluid resuscitation

6. In the event of septic shock or lactate >4 mmol/l, CVP and ScvO2 or SvO2 measured

7. In the event of septic shock or lactate >4 mmol/l, CVP maintained 8-12 mmHg (12-15 in AV), i.e. 10-15 cmH2O (15-20 in AV)

8. Inotropes (and/or PRBCs if hematocrit 30%) delivered for ScvO2 <70% or SvO2 < 65% if CVP 8 mmHg

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Sepsis Bundle

24-Hour Severe Sepsis Bundle: Tasks that must be done within 24

hours for patients with severe sepsis, severe sepsis with lactate >4

mmol/l, septic shock.

Changes for Improvement

1. Glucose control maintained <150 mg/dl (8.3 mmol/l)

2. Drotrecogin alfa (activated) administered in accordance with

hospital guidelines

3. Steroids given for septic shock requiring continued use of

vasopressors for equal to or greater than 6 hours

4. Adoption of a lung protective strategy with plateau pressures 30

cmH2o for mechanically ventilated patients

Surviving Sepsis Campaign and the Institute for Healthcare Improvement, Boston, Massachusetts, USA

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Changes/

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Sepsis Bundles Sepsis Resuscitation Bundle:

1. Serum lactate measured

2. Blood cultures obtained prior to antibiotic administration

3. Broad-spectrum antibiotics administered

4. Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent)

5. Apply vasopressors for hypotension not responding to initial fluid resuscitation

6. Achieve central venous pressure (CVP) of > 8 mm Hg

7. Achieve central venous oxygen saturation (ScvO2) of > 70%

Sepsis Management Bundle:

1. Low-dose steroids administered for septic shock

2. Drotrecogin alfa (activated) administered

3. Glucose control maintained > lower limit of normal, but < 150 mg/dl (8.3 mmol/L)

4. Inspiratory plateau pressures maintained < 30 cm H2O for mechanically ventilated patients

The key components of the Ventilator Bundle are:

1. Elevation of the Head of the Bed

2. Daily "Sedation Vacations" and Assessment of Readiness to Extubate

3. Peptic Ulcer Disease Prophylaxis

4. Deep Venous Thrombosis Prophylaxis

The key components of the Central Line Bundle are:

1. Hand Hygiene

2. Maximal Barrier Precautions Upon Insertion

3. Chlorhexidine Skin Antisepsis

4. Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site for Non-Tunneled Catheters

5. Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Changes

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CAVH

CVVH

CAVHD

CVVHD

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CARDIOGENIC SHOCK

• Inhalácia kyslíka, resp. UPV

• Analgézia (Fentanyl, Morfin)

MgSO4 20% 10 ml, Cardilan 20 ml,

Skorá podpora dýchania

Kombinácia vazoaktívnych látok

(nitroglycerín + dobutamin)

Trombolýza?

Intraaortálna kontrapulzácia?

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33 BA

LO

ON

CO

NT

RA

-PU

LS

AT

ION

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systola - diastola

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MODS – MSOF (Kerr, PGA55)

Organs – system

1. Lungs

2. Kidney

3. Cardiovascular

4. CNS

5. Periph. NS

6. Coagulation

7. Gastrointestinal

8. Liver

9. Suprarenal gland

10. Skeletal muscles

Clin. syndromme

1. ARDS

2. Acute tubul. necrosis

3. Hyperdyn hypotension

4. Metab encepahlopaty

5. Polyneuropathy

6. DIC

7. Gastroparesis, ileus

8. Non-inf hepatitis

9. Acute supraren insuf

10. Rhabdomyolysis

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Hypothesis: Gut as STARTER

of multiorgan failure

Neuroendocrine response

Splanchnic

blood flow

Gut ischaemia

Reperfusion

PLA2

PAF

Activation

of PMN

System

impact PMN MSOF

Initial

diagnosis

Kirton, Civetta, Critical Care 1997